For internal medicine specialists, precise and thorough clinical documentation is crucial. Hospitalist progress notes provide an ongoing record of a patient's hospital stay, detailing their clinical status and treatment plan. Below, we guide you through creating a well-structured progress note using a detailed example.

Clinical Course

Begin with the Clinical Course, outlining the patient's background and current status. For instance, "Patient is a 68-year-old male with a history of hypertension, type 2 diabetes, and chronic kidney disease, admitted for pneumonia with complaints of shortness of breath and fever. He is on IV antibiotics and oxygen therapy, showing gradual improvement."

Today's Updates

Provide updates on the patient's condition. For example, "As of 10/15/2023, the patient's condition has stabilized, with no significant changes in the past 24 hours. He continues to respond well to the antibiotics."

Relevant Imaging and Test Results

Include pertinent imaging and test results. "Chest X-ray shows resolving infiltrates in the right lower lobe. Blood cultures are negative, and inflammatory markers have decreased."

Review of Systems (ROS)

Document any new findings or state, "No new positive or negative findings reported."

Physical Exam

Conduct a comprehensive physical examination. Example: "General: Alert, well-nourished, no distress. Lungs: Clear, non-labored. Heart: Normal rate and rhythm, no murmur. Abdomen: Soft, non-tender. Musculoskeletal: No cyanosis. Neurologic: No weakness. Psychiatric: Cooperative."

Assessment and Plan

Detail the assessment and plan for each issue. For pneumonia, "Assessment: Improving. Plan: Continue IV antibiotics, monitor status. Counseling: Importance of completing antibiotics." For hypertension, "Assessment: Well-controlled. Plan: Continue regimen." For diabetes, "Assessment: Stable glucose levels. Plan: Continue management, monitor levels."

Manual documentation can be time-consuming, often detracting from patient care. This is where AI medical scribes like Notis AI Medical Scribe come into play, streamlining the documentation process for internal medicine specialists.

How Notis AI Medical Scribe Improves Documentation

Notis AI Medical Scribe significantly reduces documentation time by converting voice interactions into structured SOAP notes, allowing healthcare providers to focus more on patient care. With its integration through WhatsApp, Notis is user-friendly, requiring no new software. The platform's high accuracy in transcription ensures reliable documentation, supporting internal medicine specialists in maintaining comprehensive and precise patient records.

By leveraging AI scribes, specialists can enhance efficiency and accuracy in clinical documentation, ultimately improving patient care and reducing clinician burnout. The use of AI medical scribes represents a significant advancement in patient charting, offering an invaluable tool for healthcare professionals.